Calcaneal apophysitis, commonly referred to as Sever’s disease, is a painful condition affecting the heel in growing children and adolescents. Despite its name, it is not a true disease but rather an overuse injury involving inflammation of the growth plate in the heel bone (calcaneus). This condition is particularly prevalent among physically active youth, especially those engaged in sports that involve running and jumping. Understanding the causes, symptoms, diagnosis, and treatment of calcaneal apophysitis is essential for parents, coaches, and healthcare providers to ensure timely intervention and recovery.

Pathophysiology

The calcaneus, or heel bone, develops from two ossification centers: one begins at birth, and the other typically appears after age 8. Complete ossification usually occurs by age 15. During this period, the growth plate (apophysis) at the back of the heel remains vulnerable to stress and strain. Calcaneal apophysitis arises when repetitive microtrauma—often from sports or physical activity—causes inflammation at this growth plate.

The Achilles tendon, which connects the calf muscles to the heel, inserts directly into the calcaneal apophysis. During growth spurts, bones often grow faster than muscles and tendons can adapt, leading to increased tension at this insertion point. This tension, combined with high-impact activities, can result in painful inflammation and disruption of the apophyseal cartilage.

Risk Factors

Several factors contribute to the development of calcaneal apophysitis:

• Age: Most commonly affects children aged 9 to 14, during periods of rapid growth.
• Activity Level: High-impact sports such as soccer, basketball, gymnastics, and track increase risk due to repetitive heel stress.
• Footwear: Flat shoes or cleats without heel elevation exacerbate stress on the heel.
• Biomechanics: Tight calf muscles, high plantar pressures, and poor foot mechanics (e.g., overpronation) may contribute.
• Obesity: Excess body weight can increase heel pressure, although evidence on this is mixed.

Clinical Presentation

Children with calcaneal apophysitis typically present with:

• Heel pain: Especially at the back or sides of the heel, worsened by activity and relieved by rest.
• Tenderness: Localized over the calcaneal apophysis.
• Swelling and warmth: Occasionally present.
• Limping or toe-walking: To avoid heel contact.
• Bilateral symptoms: Both heels may be affected, though one side is often worse.

Pain is often aggravated by running, jumping, or standing on tiptoes. The condition may develop gradually or suddenly, depending on activity levels and biomechanical stress.

Diagnosis

Diagnosis of calcaneal apophysitis is primarily clinical. A thorough history and physical examination are usually sufficient. Key diagnostic steps include:

• Palpation: Tenderness over the posterior heel.
• Functional tests: Pain during heel squeeze or toe walking.
• Imaging: X-rays are typically not helpful, as the appearance of the growth plate may be normal even in symptomatic children. However, imaging may be used to rule out other conditions such as fractures or infections. MRI can show marrow edema or retrocalcaneal bursitis in more complex cases.

Treatment

Calcaneal apophysitis is a self-limiting condition that resolves with skeletal maturity. However, symptom management is crucial to maintain activity levels and prevent long-term discomfort. Treatment strategies include:

Rest and Activity Modification

• Reducing or temporarily stopping high-impact activities.
• Switching to low-impact exercises like swimming or cycling.

Stretching and Physical Therapy

• Achilles tendon stretching: Both passive and active techniques help reduce tension on the heel.
• Calf muscle flexibility: Night splints or stretching routines can maintain muscle length during growth spurts.

Footwear and Orthotics

• Heel cups or pads: Provide cushioning and reduce strain.
• Elevated heels: Alleviate Achilles tension.
• Supportive shoes: Avoid flat soles and ensure proper arch support.

Medications

• NSAIDs: Nonsteroidal anti-inflammatory drugs like ibuprofen can relieve pain and inflammation.

Ice Therapy

• Applying ice packs to the heel after activity can reduce swelling and discomfort.

In severe cases, immobilization with a cast or walking boot may be necessary to allow complete rest of the heel.

Prognosis

The prognosis for calcaneal apophysitis is excellent. Most children recover fully with conservative treatment and return to normal activities within weeks to months. The condition typically resolves once the growth plate closes during adolescence. However, recurrence is possible if activity resumes too quickly or without proper biomechanical correction.

Prevention

Preventive measures can reduce the risk of developing calcaneal apophysitis:

• Gradual increase in activity: Avoid sudden spikes in training intensity.
• Proper warm-up and stretching: Especially for the calf muscles and Achilles tendon.
• Appropriate footwear: Use shoes with cushioning and heel support.
• Cross-training: Incorporate low-impact activities to reduce repetitive heel stress.
• Monitoring growth spurts: Adjust activity levels during periods of rapid growth.

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Calcaneal apophysitis is a common and treatable condition in growing children, particularly those engaged in sports. While it can cause significant discomfort and limit activity, early recognition and appropriate management lead to excellent outcomes. By understanding the underlying causes and implementing preventive strategies, caregivers and healthcare providers can support young athletes through their growth and development without compromising their physical well-being.